DHS Home

Division of Mental Health and Addiction Services Home

Consumer Resources and Services

Major Initiatives

Forms

Providers/Stakeholders: Contracting, Funding Opportunities, Licensing, Public Notices

Regulations and Administrative Bulletins

Publications/Research/Reports

Information Center/Announcements

• Advance Directives (Psychiatric)
  
• Commitment
  
• Detainer
  
• Integrated Case Management Services (ICMS)
  
• Police Transport and Supervision
  
• Pre-Admission Screening Resident Review (PASRR)
  
• Quarterly Contract Monitoring Forms (QCMR)
  
• Screening
  
• State Psychiatric Interfacility Transfers
  
• Unified Services Transaction Forms (USTF)
  
• Unusual Incident Reporting Forms
  
• Miscellaneous Forms
  

Advance Directives (Psychiatric)

Click here to go to the Psychiatric Advance Directives page.

---

 

Application for Involuntary Commitment (posted January 2013)
Clinical/Screening Certificate for Involuntary Commitment for Mentally Ill Adults (September 2014)
Temporary Order for Involuntary Commitment to Treatment of an Adult (Outpatient Treatment)
Temporary Order for Involuntary Commitment to Treatment of an Adult (Inpatient Treatment)

---

Detainer

Detainer Form (posted October 2007)

---

Integrated Case Management Services (ICMS)

ICMS Forms:     (Community)     (Interim)

ICMS Termination Request (October 2011)

---

Police Transport and Supervision

Request for Police Transport and Supervision (Outpatient Treatment)
Request for Police Transport and Supervision (Screening Outreach)

---

Pre-Admission Screening Resident Review (PASRR)

Categorical Determination Psychiatric Evaluation (revised March, 2015)
Level II Psychiatric Evaluation Form (revised January, 2019)
Level II Psychiatric Evaluation Webinar Training (January 2019)
Instructions for Completing the Revised Level II PASRR Psychiatric Evaluation Form
Resident Review Form

---

Quarterly Contract Monitoring Forms (QCMR)

Click here to go to the DMHAS Contracting page.

---

Screening

Clinical/Screening Certificate for Involuntary Commitment for Mentally Ill Adults (September 2014)
Screening Document for Adults (May 2017) 

---

State Psychiatric Interfacility Transfers

N.J. DMHAS Letter to Providers
N.J. Department of Health Letter to Healthcare Facility Providers
Instructions
Transfer Form
Inpatient Interfacility Transfer Form

---

Unified Services Transaction Forms (USTF)

You can e-mail your USTF data to:   dmhs.ustf@dhs.state.nj.us

Acceptance/Termination
Emergency/Screening
Incoming/Outgoing Client Transfers
Manual
Project Code Listing
Service Area Listing

---

Unusual Incident Reporting Forms

Administrative Order 2:05

DMHAS Community UIRMS Contacts  (July 2018)

Community Mental Health (MH) Provider UIRMS Training Powerpoint - October 2015 rev.January 2017

Substance Use Disorder (SUD) Provider UIRMS Training Powerpoint - October 2015 rev. January 2017

DMHAS Community Closure Addendum for MH and SUD Programs

DMHAS Category List for MH and SUD Programs

Reportable Incident Categories by Program Type for MH and SUD Treatment Providers

Process Flow Chart for MH and SUD Programs

Initial Incident Report Form for MH and SUD Programs | Paper Version | Electronic Version | Protocol for Initial Incident Report Form

Follow-up Report Form for MH and SUD Programs | Paper Version | Electronic Version | Protocol for Follow-up Report Form

DMHAS Appendix 1 for MH and SUD Programs |Paper Version | Electronic Version

DMHAS Appendix 2 - Substance Use Questionnaire for MH and SUD Programs | Paper Version | Electronic Version
DMHAS Appendix 2a - Overdose Questionnaire for MH and SUD Programs | Paper Version | Electronic Version

DMHAS Appendix 3 - Sudden and Unexpected Death Questionnaire for MH and SUD Programs | Paper Version | Electronic Version

DMHAS Appendix 4 - Suicide or Suicide Attempt Questionnaire for MH and SUD Programs |Paper Version | Electronic Version

Archives

Community Mental Health (MH) Provider UIRMS Training Powerpoint -October 2015

Substance Use Disorder (SUD) Provider UIRMS Training Powerpoint - October 2015

---

Miscellaneous Forms

Agency Referral and Response Form
Metabolic Syndrome Tracking Form
Psychotropic Medication Emergency Certification Form